From the Research
The management of a chronically elevated right hemidiaphragm should prioritize treating the underlying cause, with a focus on hepatic hydrothorax as a potential cause, and consider a multidisciplinary approach including pulmonology, hepatology, and transplant surgery. The initial evaluation should include chest radiography, ultrasound, fluoroscopy (sniff test), and possibly CT or MRI to determine etiology [ 1 ]. Common causes of a chronically elevated right hemidiaphragm include phrenic nerve injury, neuromuscular disorders, subphrenic abscess, or idiopathic elevation, but hepatic hydrothorax should be considered, especially if the patient has a history of liver disease [ 2 ].
If the patient is asymptomatic, conservative management with regular monitoring is appropriate. For symptomatic patients, treatment targets the underlying condition - antibiotics for infection, physical therapy for neuromuscular causes, or surgical intervention for structural abnormalities. In cases of hepatic hydrothorax, management options include serial thoracentesis, indwelling tunneled pleural catheter placement, and consideration of liver transplantation [ 1 ]. Pulmonary rehabilitation with breathing exercises (diaphragmatic breathing, incentive spirometry) can improve respiratory function. Patients should be monitored for respiratory compromise, particularly during respiratory infections, and pulmonary function tests should be performed periodically to assess for deterioration requiring intervention.
Some key points to consider in the management of a chronically elevated right hemidiaphragm include:
- Initial evaluation to determine etiology
- Consideration of hepatic hydrothorax as a potential cause
- Multidisciplinary approach including pulmonology, hepatology, and transplant surgery
- Treatment targeting the underlying condition
- Monitoring for respiratory compromise and deterioration
- Consideration of liver transplantation in cases of hepatic hydrothorax [ 1 ].
It is essential to prioritize the patient's morbidity, mortality, and quality of life when making management decisions, and to consider the most recent and highest quality evidence available [ 1 ].